Page 12 - Amerihealth New Jersey - Small Group - 2021 Benefits at a Glance

Emergency Room
Outpatient Surgery
Ambulatory Surgical
Inpatient Hospital Services
Including Maternity
$500 copay per day up to 5 5 days after deductible6
NEW NEW PLAN
PLAN
NEW NEW PLAN
PLAN
50% coinsurance after deductible BRONZE BENEFITS
Select EPO HSA AmeriHealth Hospital Advantage14 $50 / $75
Select EPO HSA AmeriHealth Advantage13 $25 / $50 Choose your network
Local Value5
Local Value18 Regional Preferred with NY19
MEDICAL BENEFITS
TIER 1 TIER TIER 2 TIER TIER 1 TIER 2 Deductible
Individual/family
$6 $6 000 000 000 000 / / $12 $12 00015 00015 $6 $6 000 000 000 000 / / $12 $12 00015 00015 After Deductible
Member pays
50% 30%
$7 $7 000 000 000 000 / / $14 $14 00016 00016 $7 $7 000 000 000 000 / / $14 $14 00016 00016 50% Maximum Out-of-pocket
Individual/family
Primary Care Visits
$50 copay after deductible10
$25 copay after deductible10
50% coinsurance after deductible10
Specialist Visits
$75
copay after deductible $50 copay after deductible 50% coinsurance after deductible Urgent Care Services
50% coinsurance after deductible 30%
coinsurance after deductible 30%
coinsurance after deductible 50% coinsurance after deductible 20% coinsurance after deductible 50% coinsurance coinsurance 30%
coinsurance coinsurance after after deductible deductible deductible deductible X-rays & Diagnostic Imaging
Imaging
CT/PT Scans MRIs
50% 50% coinsurance coinsurance after after deductible deductible 50% 50% coinsurance coinsurance after after deductible deductible Laboratory12
50% 50% coinsurance coinsurance after after deductible deductible 50% 50% coinsurance coinsurance after after deductible deductible Inpatient Treatment
Mental Behavioral Health Substance Use Disorder
$500 copay per day day up to 5 5 days after deductible6
30%
coinsurance after deductible Outpatient Treatment
Mental Behavioral Health Substance Use Disorder
$75
copay copay after after deductible deductible $50 copay copay after after deductible deductible Rehabilitation Therapy Services3
$75
copay copay after after deductible deductible $50 copay copay after after deductible deductible Chiropractic Care2
Durable Medical Equipment
PRESCRIPTION BENEFITS
50% 50% coinsurance coinsurance after after deductible deductible 50% 50% coinsurance coinsurance after after deductible deductible 30 30 DAY DAY SUPPLY4 SUPPLY4 30 30 DAY DAY SUPPLY4 SUPPLY4 Generic Rx
50% coinsurance up to $125 max after deductible 50% coinsurance up to $125 max after deductible Brand Rx
Non-preferred brand Rx
$ are a a a a a a a a a guide for plan costs within each metallic tier Network variations may impact cost cost 10